Brief Encounters of the NHS Kind

Do you remember the suave Dr Alec Harvey? If you are under the age of 70 you probably don’t. I will reveal the answer later, promise. He was an enigma. He was also a rascal, although ultimately, he was a gentleman. He was an idealistic GP, who also practiced one day week as a Consultant in an acute hospital. Last week I also heard he was possibly a great example of a doctor who knew about public health practice as well as someone who treats whatever is presented in front of him/her.

There is something in this thought. Most of our clinical colleagues are educated, trained, and prepared to deal with whatever medical problem is presented. Many do so with great skill, knowledge, and leadership. However, and I didn't know this, you can actually train to become a Public Health practitioner (enabling you to be qualified as a Public Health Consultant) with  or without a medical degree. I think this training and education might equip students with different leadership skills than those found in most doctors. Don’t get me wrong, I think we need doctors and other clinical staff with both sets of skills and knowledge. However, as demand for health care continues to grow, partly driven by ever increasing numbers of people living with long term and complex health needs and partly because of the pandemic legacy of untreated conditions, I wonder if the NHS will have enough resources to meet all these demands. I fear not.

Last week it was agreed that the NHS will receive an additional £6.6 billion to help pay for the additional costs of Covid and the recovery of the elective programme of treatments and care. Although the longer term funding of the NHS still needs to be resolved, this is welcome news indeed. In addition, an extra £341 million has been provided for adult social care services – most of which will help ensure infection prevention and control measures are maintained. You can read the details of these additional payments here.

Welcome as these additional resources are, I think the NHS is still left with a longer-term funding issue. Very few cost improvement savings will have been made last year. Many hospitals have underlying financial deficits (often many millions of pounds) that have been largely hidden from sight by the command and control pandemic funding flows – but they are still there. In addition, the NHS has  a ‘backlog maintenance’ bill of some £9 billion, which is almost as much as it costs to run the NHS estates each year, which includes heating and lighting buildings, feeding patients, keeping hospitals clean and so on. Backlog maintenance costs are calculated on what would be required to restore a building to its optimum level of functioning. Strangely, it does not include or reflect any planned maintenance work. Many hospital and community services suffer from buildings that struggle to meet today’s accommodation standards. The pandemic revealed the difficulties many hospitals had in ensuring adequate ventilation for example.   

Given the impact of the pandemic on the UK’s economic resilience, I find it hard to believe that these are issues that might be easily solved through some type of austerity programme, although I‘m sure we will see a return to a fairly long period of economic austerity in the years to come. The UK spends just over £3,000 per person on healthcare each year. The current total funding of the NHS is £130 billion, which will rise to £136bn by 2022. That is a lot of money.

I wondered what you might spend that kind of money on to solve some of the world’s wicked problems. One of the first things to pop up in my search was an advertisement for a book entitled ‘How to Spend $75 Billion to make the World a Better place’. I have not read the book so cannot vouch for its veracity, but you get a flavour of the sort of things you could do with a fraction of that kind of money. I also wondered, if I were Prime Minister, what would I do or how might I spend the money to make the NHS a better place too? I think it would have to be spent on tackling the social determinants that promote or inhibit good health and wellbeing.

Some 40 years ago now, another famous GP, Dr Julian Tudor-Hart published a paper in The Lancet that discussed the issue of the inverse care law. He was a pioneering research-based GP, very much into preventive approaches to medical practice, and using data to underpin policy development. His inverse care law describes the somewhat perverse relationship between the need for health care and its actual uptake. He suggested that those who most needed medical care are least likely to receive it. Conversely, those with least need of health care will tend to use health services more and probably do so more effectively.

His work has been built upon by many other researchers and clinicians. I think his voice is not heard as often and as loudly as it should be these days. Public health has become the metaphorical Cinderella in a pandemic-dominated world. However, there are some who are doing things that might provide a clue to possible ways forward. For example, one of the stories I read last week was one citing the outrage at the London Mayor Sadiq Khan’s recent air pollution initiative. This is the so called Ultra Low Emissions Zone (ULEZ) charge (£12.50 a day) levied on older vehicles entering the London congestion zone. According to Living Streets, the UK school run produces the same amount of carbon emissions as Greenland each year. The ULEZ initiative is calculated to save the NHS £5 billion and prevent over one million hospital admissions over the next 30 years. Now that is foresight that should be applauded. It’s also a great example of the dilemma facing many in public health in taking forward policies that will make a difference, will save money, but will only do so over time.

The outrage directed at Sadiq Khan’s initiative is that he is drives around in a £300,000 Range Rover. You perhaps need to read the full story to judge whether you think this outrage is appropriate. I don’t. And if you want to consider buying a similar Range Rover to Sadiq’s, you can find the details here.  

Oh, that other famous GP, Dr Alec Harvey? He perhaps is even more famous than Dr Tudor-Hart. He was the doctor in the 1945 film of passion, romance, suicidality, trains and tea rooms that we know and love called ‘Brief Encounter’.